Provider Demographics
NPI:1407924053
Name:SOUTHERN INDIANA UROLOGIC CLINIC,LLC
Entity Type:Organization
Organization Name:SOUTHERN INDIANA UROLOGIC CLINIC,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KARL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCALEESE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-376-9261
Mailing Address - Street 1:2475 N PARK DR STE 10
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-2215
Mailing Address - Country:US
Mailing Address - Phone:812-376-9261
Mailing Address - Fax:812-378-9518
Practice Address - Street 1:2475 N PARK DR STE 10
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-2215
Practice Address - Country:US
Practice Address - Phone:812-376-9261
Practice Address - Fax:812-378-9518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200328660Medicaid
IN183650Medicare PIN